Original Article

Prevalence of white spot lesions during orthodontic treatment with

fixed appliances
Eser Tufekcia; Julian S. Dixonb; J.C. Gunsolleyc; Steven J. Lindauerd

ABSTRACT
Objective: To determine the prevalence of white spot lesions (WSLs) in orthodontic patients at 6
and 12 months into treatment using the visual examination method.
Materials and Methods: Patients 6 and 12 months into treatment were examined for the presence
of WSLs. The control group consisted of patients who were examined for WSLs immediately after
bonding. Upon clinical evaluation, teeth were given a visual score based on the extent of
demineralization.
Results: The percentages of individuals having at least one WSL were 38%, 46%, and 11% for the
6-month, 12-month, and control groups, respectively. The 6-month (P 5 .021) and 12-month
groups (P 5 .005) were significantly different from the control group but were not significantly
different from each other (P 5 .50). Of subjects in the study who had at least one visible WSL, 76%
were males and 24% were females (P 5 .009).
Conclusions: This clinical study showed a sharp increase in the number of WSLs during the first
6 months of treatment that continued to rise at a slower rate to 12 months. Clinicians should
evaluate the oral hygiene status of patients during the initial months of treatment and, if necessary,
should implement extra measures to prevent demineralization. (Angle Orthod. 2011;81:206–210.)
KEY WORDS: White spot lesions; Prevalence; Demineralization; Dental plaque

INTRODUCTION es make conventional oral hygiene procedures more

Enamel demineralization is a significant risk associ-
ated with orthodontic treatment when oral hygiene is
poor. Prevention of demineralization during orthodon-
tic treatment is one of the greatest challenges faced by
clinicians despite modern advances in caries preven-
tion. The development of white spot lesions (WSLs) is
attributed to prolonged plaque accumulation around
the brackets.1–5 Not only do fixed orthodontic applianc-
a
Associate Professor, Department of Orthodontics, School of
Dentistry, Virginia Commonwealth University, Richmond, Va.
b
Orthodontic Resident, Department of Orthodontics, School
of Dentistry, Virginia Commonwealth University, Richmond, Va.
c
Professor, Department of Periodontics, School of Dentistry,
Virginia Commonwealth University, Richmond, Va.
d
Professor and Department Chair, Department of Orthodon-
tics, School of Dentistry, Virginia Commonwealth University,
Richmond, Va.
Corresponding author: Dr Eser Tufekci, Department of
Orthodontics, School of Dentistry, Virginia Commonwealth
University, 520 N 12th Street, PO Box 980566 Richmond, VA
23298-0566
(e-mail: etufekci@vcu.edu)
Accepted: September 2010. Submitted: May 2010.
G 2011 by The EH Angle Education and Research Foundation,
Inc.
difficult, they also increase the number of plaque
retention sites on the surfaces of the teeth that are
normally less susceptible to caries development.6
After the introduction of orthodontic fixed appliances
into the oral cavity, a rapid shift in the bacterial flora of
plaque occurs. Higher levels of acidogenic bacteria are
present in the plaque, most notably Streptococcus
mutans and Lactobacilli.7 High levels of bacteria are
capable of decreasing the pH of plaque in orthodontic
patients to a greater extent than in nonorthodontic
patients.8 Therefore, the progression of caries is faster
in patients with full orthodontic appliances. WSLs can
become noticeable around the brackets within 1 month
of bracket placement, although the formation of regular
caries usually takes at least 6 months.9 These lesions
are commonly seen on the buccal surfaces of teeth
around the brackets, especially in the gingival re-
gion.1,5,10
A review of available literature on the prevalence of
WSLs revealed that most relevant studies reported the
presence of these lesions at the completion of
orthodontic treatment. Depending on the examination
technique used, the prevalence of WSLs varies.
Gorelick et al.,1 in their study using the visual
examination technique, reported that 50% of patients

Angle Orthodontist, Vol 81, No 2, 2011 206 DOI: 10.2319/051710-262.1

PREVALENCE OF WHITE SPOT LESIONS
had one or more WSLs at the end of treatment.
Boersma et al.,11 using quantitative light fluoroscopy,
investigated the prevalence of WSLs at the end of
orthodontic treatment and reported that 97% of
subjects had one or more lesions. In light of these
studies, one may conclude that demineralization is a
significant clinical problem resulting in an unacceptable
esthetic presentation that, in some severe cases, may
require restorative treatment.
Even though it was reported previously that WSLs
can develop within 1 month, the formation of these
lesions and their prevalence at different time points
during orthodontic treatment have not been investigat-
ed. Early detection of WSLs during orthodontic
treatment is of great importance, as it would allow
clinicians to implement preventive measures to control
the demineralization process before lesions progress.
Therefore, the objective of this study was to determine
the prevalence of white spot lesions using the visual
examination method in orthodontic patients before
orthodontic treatment and at 6 and 12 months into
treatment.
MATERIALS AND METHODS
Before the start of this cross-sectional clinical study,
approval was obtained from the Institutional Review
Board of the Virginia Commonwealth University (VCU)
Office of Research. Subjects 12 years and older with
complete initial records who agreed to participate in
the study were recruited among patients who were
being treated with fixed orthodontic appliances at the
VCU Orthodontic Clinic. Patients on a daily supple-
mental fluoride regimen were excluded from the study.
A research assistant searched the schedule at the
VCU Department of Orthodontics at the start of each
week for patients who met the requirements. Previ-
ously identified subjects were then asked if they would
participate in the study, and informed consent was
obtained. Measurements were performed on all
patients enrolled in the study by the same clinician
who was blind as to the patient’s time frame for
orthodontic therapy. The clinician evaluated subjects
only after wires and auxiliary attachments had been
removed by the orthodontic assistant, thus minimizing
the availability of information that would otherwise
indicate the duration of previous treatment. Following
these measurements, the name of the group to which
the patient belonged was added to the examination
form by the research assistant.
The patient’s date of birth, race, and gender, along
with visual examination findings, were recorded on a
clinical form with the treatment group section left blank.
Before measurements were taken, maxillary teeth from
the right second premolar to the left second premolar
207
were isolated with cotton rolls and air-dried for
5 seconds. Only tooth surfaces gingival to the archwire
were examined for the presence of WSLs, as this is the
area most prone to enamel demineralization during
orthodontic treatment. The following scale was used
for the visual examination:
Score 0 5 No visible white spots or surface
disruption (no demineralization)
Score 1 5 Visible white spot without surface
disruption (mild demineralization)
Score 2 5 Visible white spot lesion having a
roughened surface but not requiring a restoration
(moderate demineralization)
Score 3 5 Visible white spot lesion requiring
restoration (severe demineralization)
Statistical Analysis
The three groups (6-month, 12-month, and control)
were evaluated for differences in the prevalence of
having at least one white spot lesion by chi square
analysis and were followed by Fisher’s exact test. To
evaluate the multiple effects of group (time in therapy)
and gender, and to determine interactions between
groups and gender, logistic regression was used.
Differences in the mean number of white spots
between groups were analyzed using analysis of
variance. The prevalence of white spots by tooth type
was evaluated with logistic regression. The signifi-
cance level was set at P , .05.
RESULTS
The study consisted of three groups of patients
who were examined for the presence of enamel
demineralization. The 6-month group consisted of
37 subjects (16 females, 21 males) with a mean
age of 17.4 6 1.3 years who were 6 months
(63 weeks) into orthodontic treatment. The 12-month
group consisted of 35 patients (18 females, 17 males)
with a mean age of 17.5 6 1.4 years who were
12 months (64 weeks) into orthodontic treatment. The
control group consisted of 28 patients (13 females, 15
males) with a mean age of 15.1 6 1.5 years who were
examined for WSLs immediately after braces were
placed on their teeth.
The frequency of individuals having a WSL upon
visual examination is presented in Table 1. In the 6-
and 12-month groups, the percentages of individuals
having at least one visible WSL were 38% and 46%,
respectively. In the control group, only 11% of the
sample had at least one WSL. The 6-month (P 5 .021)
and 12-month groups (P 5 .005) were significantly
different from the control group but were not signifi-
cantly different from each other (P 5 .50).
Angle Orthodontist, Vol 81, No 2, 2011
208
Table 1. Frequency of Individuals With WSLsa
Group No WSL, n (%) WSL Present, n (%)
12 month 19 (54) 16 (46)
6 month 23 (62) 14 (38)
Control 25 (89) 3 (11)
a Control
The control group had a lower prevalence of individuals with
white spot lesions than the 6-month group (P 5 .02, Fisher’s exact
test) and the 12-month group (P 5 .005, Fisher’s exact test). The 6-
month and 12-month groups were not significantly different from
each other.
Table 2 presents the distribution of the white spots
in greater detail. In the 6-month group, 23 patients had
no detectable WSLs (62%), 8 patients had between 1
and 3 WSLs with visual scores of 1 and 2 (22%), and 6
patients had greater than or equal to 4 WSLs with
visual scores of 1 and 2 (16%). In some cases, all six
of the maxillary anterior teeth presented with WSLs.
The 12-month group was similar with 19 patients
unaffected (54%), 12 patients with one to three white
spot lesions with visual scores of 1 (34%), and 4
patients with greater than or equal to four lesions per
individual with visual scores of 2 and 3 (12%). In both
groups, a great amount of individual variability was
noted among patients, with some displaying no
demineralization and others having WSLs almost on
each tooth. However, almost 90% of the control group
did not have any WSLs on the day of their bonding,
and all of the remaining 10% had between one and
three WSLs per patient.
When the gender effect on WSL development was
evaluated, a statistically significant difference (P 5
.009) was noted in the prevalence of WSLs between
males and females (Table 3). In the 6-month group, 11
of 21 males (52%) had at least one WSL, as opposed
to only 3 of 16 females (19%) within this group. In the
12-month group, 12 of 17 males (71%) developed at
least one WSL. In the same group, the number of
females who had at least one lesion was only 4 of 18
(22%). Overall, 76% of subjects in the study who had
at least one visible white spot were males and 24%
were females.
No statistically significant differences were noted in
the distribution of WSLs among different types of teeth
(maxillary central incisors, maxillary lateral incisors,
Table 2. Distribution of WSLs per Individuala
Group Mean WSLs/Patient (6SD) No WSLs, n (%)
12 month 1.13 6 0.22 19 (54)
6 month 0.92 6 0.22 23 (62)
Control 0.14 6 0.24 25 (89)
a
Following are the results of analysis of variance with number of white spots per patient as the outcome variable: Group (P 5 .01), and gender
(P 5 .0003), were statistically significant; however, the interaction between the two was not significant. Tukey’s honestly significant difference
(HSD) showed that the 12-month and 6-month groups were not significantly different from each other but were significantly different from the
control group (P # .05).
Angle Orthodontist, Vol 81, No 2, 2011
TUFEKCI, DIXON, GUNSOLLEY, LINDAUER
Table 3. Gender Effect on White Spot Lesion Formationa
Number (%) of Males Number (%) of Females
Group With WSL With WSL
12 month 12 (71) 4 (22)
6 month 11 (52) 3 (19)
2 (7) 1 (8)
a
Following are the results of logistic regression analysis of the
prevalence of individuals with white spot lesions: Group (P 5 .01),
and gender (P 5 .009), were statistically significant; however the
interaction between the two was not significant.
and maxillary canines), indicating that all types of teeth
were equally subjected to demineralization.
DISCUSSION
Results of the present study indicate that WSLs
remain a considerable problem during orthodontic
treatment. Fixed appliances serve as plaque retention
sites, and, in the absence of good oral hygiene, plaque
accumulates and acidogenic bacteria cause marked
demineralization. In this study, 38% of subjects had a
visual WSL 6 months into treatment; this number
increased to 46% for the 12-month group. Only 11% of
the control group presented with at least one white
spot lesion. Gorelick et al.1 reported a prevalence of
about 50% in their study, which examined the
presence of WSLs at the end of orthodontic treatment.
A higher prevalence in that study may be attributed to
the inclusion of both maxillary and mandibular teeth,
and to the length of the orthodontic treatment (about
24 months), as opposed to the examination of the
maxillary teeth from canine to canine at 6 and
12 months into orthodontic treatment.
Detecting WSLs during active treatment can be
challenging for the clinician. The clinical crown must be
free from plaque and debris, and the presence of
excess gingival tissue can make visualization of WSLs
difficult. Furthermore, to detect incipient WSLs, the
tooth must be air-dried. If these steps are not followed,
a WSL could easily be overlooked. Therefore, a
thorough examination of each patient should be done
at each appointment, and each patient should receive
a customized oral hygiene treatment regimen to halt
the progression of any demineralization.
1 to 3 WSLs, n (%) $4 WSLs, n (%)
12 (34) 4 (12)
8 (22) 6 (16)
3 (11) 0 (0)
PREVALENCE OF WHITE SPOT LESIONS
In this study, it was possible to examine only the
maxillary anterior teeth because the premolar tooth
surfaces gingival to the archwire were generally
covered by inflamed gingiva. This was probably due
to more frequent gingival bracket placement on the
premolars, as well as to gingival hyperplasia and
inflammation that resulted from poor oral hygiene. To
create cleansable and accessible tooth surfaces that
would be less prone to inflammation and demineral-
ization, laser gingivectomy has been recommended for
teeth with inadequate space between the gingival
margin and the bracket.12
In the literature, conflicting reports have described
the distribution of WSLs. Gorelick et al.1 reported that
the tooth most commonly affected was the maxillary
lateral incisor. On the other hand, Mizrahi13 concluded
that the maxillary and mandibular first molars were the
teeth most commonly affected. In a later study,
Øgaard5 agreed with Mizrahi’s conclusions. In con-
trast, Geiger et al.4 reported that lesions occurred most
frequently on maxillary lateral incisors and canines.
The present study, however, found no significant
differences among teeth in the distribution of WSLs
at 6 months, at 12 months, or on the day of bonding
(control).
The high prevalence of WSLs at 6 months into active
orthodontic treatment suggests that demineralization
can quickly become a concern in the presence of fixed
appliances when oral hygiene is poor. According to
Øgaard et al.,9 these lesions can become noticeable
around the brackets within 1 month of bonding.
Therefore, it is important for the clinician to recognize
inadequate oral hygiene early, so that preventive
measures can be implemented before the develop-
ment of WSLs occurs.
In this study, the 6- and 12-month groups had an
average of 1.03 and 1.11 white spots per individual,
respectively, but these averages may be deceiving, as
many patients had a much larger problem with
demineralization. For instance, of subjects in the 6-
month group with WSLs, 43% had four or more lesions
in the maxillary anterior segment. However, not all
subjects had such a severe problem, and individual
results reflected a great amount of variability.
Another interesting finding of the study was the
overwhelming difference between the prevalence of
white spot lesions in males and females. Of subjects
who had at least one white spot lesion, 76% were
male. These findings differ from Gorelick’s findings.1 In
that study, the incidence was 44% for boys and 54%
for girls. However, a more recent study by Boersma11
found that 40% of the buccal surfaces in males had
demineralization compared with 22% in females. One
possible explanation for these results is that females
are generally more compliant orthodontic patients.14,15
209
CONCLUSIONS
N Most of the patients undergoing orthodontic treat-
ment had at least one white spot lesion in a mild
form, but a few patients presented with moderate or
severe demineralization. The prevalence of white
spot lesions was 38% in the 6-month group, whereas
it was 46% in the 12-month group.
N Given the high number of lesions found at 6 months,
it is therefore of great importance to evaluate the oral
hygiene status of patients during the initial months of
orthodontic treatment and, if necessary, to imple-
ment preventive measures immediately to prevent
demineralization.
ACKNOWLEDGMENTS
This research was supported by a grant from Johnson &
Johnson Healthcare Products Division of McNeil-PPC, Inc, and
the VCU School of Dentistry Alexander Fellowship Fund.
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